A Small-Town Clinic Looms Large as a Top Source of Disputed Painkillers

By BARRY MEIER

Published: February 10, 2002

The two doctors in tiny Grover, N.C., are separated by a few streets, a world of trouble and a tiny drugstore crammed inside a house trailer that is this country's biggest retailer of the painkiller OxyContin.

Sharing a parking lot with that drugstore is a clinic run by one physician, Dr. Joseph H. Talley, a self-styled specialist in pain treatment described by some of his patients as their best hope for relief.

But the town's other doctor, Dr. Philip M. Day, says he has watched the pain clinic's growing practice with concern that some of Dr. Talley's clientele may be going to Grover not seeking treatment but for a narcotic high.

Dr. Talley's practice is now in question. Late last month, the federal Drug Enforcement Administration suspended Dr. Talley's license to prescribe controlled substances, a regulatory classification that includes narcotics like OxyContin but not more commonly used drugs like penicillin. The agency called Dr. Talley an ''imminent threat to public health and safety,'' charging that he had prescribed drugs like OxyContin and methadone, which is also used as a pain medication, to patients who were drug dealers or drug abusers. The agency said that at least 23 of Dr. Talley's former patients had died ''in part, due to drug overdoses.''

The action follows a complaint by the North Carolina Medical Board in October against Dr. Talley charging that he had failed, among other things, to examine patients properly before prescribing narcotics or to monitor how they used the drugs.

Dr. Talley disputed the drug agency's charges and the complaint by the medical board and said he planned to contest them. He said that while he was aware that some of his patients had died, he had no way of knowing that they had been drug abusers or whether drugs he prescribed had played any role in their deaths. ''We don't have any way to know that,'' Dr. Talley said. ''Some of these people are skilled and they'll get by you.''

As misuse of OxyContin has spread nationwide, lawmakers and others have looked to possible causes like the aggressive promotion of the drug by its producer, Purdue Pharma of Stamford, Conn. But officials say that another facet of that problem may be doctors like Dr. Talley, who are so enthusiastic about the useful role of narcotics in pain treatment that they become targets for drug seekers or fail to detect patients prone to addiction.

Dr. Talley makes no bones about his lack of formal training in pain. An outgoing man who in his light blue exam coat and suspenders looks the part of the country doctor, he jokes that he would fail any tough test to certify him as a pain expert because he only uses drugs to treat pain. While many specialists scrutinize patients' drug use with urine tests and other means to see whether they are taking narcotics as prescribed or possibly selling them on the street, Dr. Talley says he does not use such tests because they are unreliable.

He said addiction through prescribed use of narcotics was relatively rare. He pointed to studies championed by pain management experts in the mid-1990's that found that chronic pain patients could be safely treated with narcotics without fear of addiction.

''When I heard about those studies, I was dancing in the street,'' said Dr. Talley, 64, who until recently specialized in treating depression.

But some pain experts cautioned that those studies may have limited value because they involved patients in controlled settings like hospitals rather than the public.

Dr. Day, the other doctor in Grover, a town of 600 people on the South Carolina border, said he still respected Dr. Talley but believed that he may have lost the ability in recent years to distinguish real patients from others seeking drugs for themselves or to sell. ''If a doctor is not careful, patients are going to start running the office,'' Dr. Day said. ''I think he lost his grip.''

Dr. Talley said he became a pain specialist almost by accident about three years ago. At that time, the federal authorities shut down a South Carolina doctor accused of improperly prescribing narcotics, and he inherited that doctor's patients. Then, as more doctors faced regulatory action or scrutiny, more patients followed.

His name soon circulated among pain sufferers and on an Internet site run by the American Society for Action on Pain, a patient group that argues that doctors have long failed to treat pain properly because of unfounded addiction fears.

A few days before Dr. Talley lost his right to prescribe narcotics, Desiree Malone, who said she found his name through the group's Web site, sat in his treatment room, her head and shoulders hunched together.

Ms. Malone said she had suffered incessant pain since a car accident two years ago that crushed and broke bones. Many doctors, she said, refused to treat her with long-acting narcotics like OxyContin, saying they feared scrutiny by the drug agency. Ms. Malone said she found relief from Dr. Talley, who prescribed a high dose of OxyContin.

''I can't believe anyone would want to do anything to Dr. Talley,'' said Ms. Malone, 37. ''All this man does is take care of patients.''

But other patients of Dr. Talley's have come to the attention of law enforcement officials. In December, federal officials arrested Debra Lynn Morris, charging her with conspiracy to distribute OxyContin and methadone illegally.

Dr. Talley said he heard rumors about a year ago of two overdose deaths in Ms. Morris's apartment but said he had continued to prescribe her narcotics because he was unable to confirm the rumors with the local authorities.

It was not long after the arrest of Ms. Morris, who has pleaded not guilty, that federal drug enforcement agents arrived at the Medi-Fair Drug Center, the tiny pharmacy here that shares a parking lot with Dr. Talley's clinic.

An owner, Billy Wease, said a federal drug agent told him that agency data showed that the pharmacy was the largest retailer of OxyContin in the nation. He said that most of those prescriptions came from Dr. Talley's clinic, which until recently employed two other doctors.

''I didn't realize we were No. 1,'' Mr. Wease said. ''All I was filing was what was coming through.''

Dr. Talley said he, too, was struck by the federal data. He said that the clinic treated about 1,000 patients and that about 30 percent of the prescriptions he wrote were for OxyContin. ''That automatically makes me the biggest prescriber of OxyContin in the U.S.,'' he said. That means that there are ''a lot of guys out there who are not doing their job by prescribing this drug,'' he said.

Federal and state law enforcement officials declined to be interviewed for this article other than to say that a criminal investigation was under way and that the pharmacy data were accurate.

Dr. Talley said that he trusted his patients and that if a few drug abusers slipped by him, there was just so much he could do. ''If the addict fools me and gets his fix, well at least he got a safe drug to abuse,'' he said. ''But if I tell this guy in terrific pain I'm not going to treat his pain and I think you are an addict, that just adds insult to injury. It is just devastating.''

He said that with his permit to prescribe narcotics suspended, he had been working nonstop to find other doctors and clinics to see his patients. Ms. Malone, the accident victim, said she had lined up a doctor, though the change will require her to drive eight hours, to Virginia.

But Dr. Day said he feared his practice would be flooded with patients going through drug withdrawal. He said he had already had to wean some of Dr. Talley's patients off drugs when they felt they could not get that help at the clinic.

''He knew this was going to happen,'' Dr. Day said. ''We had talked about it. I have a hard time with his tremendous use of these medications and deaths of patients that could have been prevented.''

Dr. Talley said any patient who wanted to stop using narcotics could get that help at the clinic. As for his ability to tell good patients from bad ones, Dr. Talley said he was inclined to wait for someone besides Dr. Day to make that call.

''I'll find out what my batting average was when I meet St. Peter,'' Dr. Talley said. ''Maybe I got 19 out of 20 right. Maybe I did 50-50. That's what I'll be judged on.''

Photos: Dr. Joseph H. Talley, above, says prescriptions he wrote for OxyContin were to provide relief to people in pain. But Dr. Philip M. Day, below, says Dr. Talley became a pawn of addicts and should have known better. (Photographs by Nell Redmond for The New York Times)